Resident Application

Name *

First

Last

Address

Address Line 2

City

State

Phone

Best time to call this phone number?

Morning
Afternoon
Evening

Date of Birth

Email *

List all your alcohol/drug use and recovery dates: *

What does recovery mean to you? Please explain how recovery plays a part in all areas of your life.

How do you see academics enhancing your recovery and supporting your objectives?

School Attending/To Be Attended:

Admission Date/Course of Study/Credits per Semester:

Current Status

How are you connected to your current recovery community (home group, treatment center, church fellowship, sponsor, etc)? How will you connect to the Madison area recovery community?

Current Employer:

Position:

How long have you worked there?

Hours per week & Income?

Volunteer Work:

Frequency:

Daily
Weekly
Monthly
Sporadically

MEDICAL - Please identify any medical conditions and age of onset that indicate a need for staff and residents to be aware or trained about your condition in order to safely aid you in times of medical crisis or could potentially pose a threat to the health of others. This should include seizure disorders, diabetes, asthma, allergies, HIV/AIDS, Hepatitis, etc. Please also list any physical limitations due to disability that may require special accommodations. The presence of a medical condition or physical disability does not constitute ineligibility for services. We ask this information for support service purposes only.

MENTAL HEALTH - Please list any previous or current mental health diagnoses and age of onset for each.

MEDICATIONS - Please list any medications prescribed for medical, mental health or substance abuse needs over the last 3 years, excluding anti-biotic treatments. Listed with each, please indicate the purpose of the medication and whether the drug is a current or discontinued prescription along with the prescribing doctor’s name.

HOSPITALIZATIONS - Please list any medical or psychiatric hospitalizations in the past 10 years. Include location, dates, duration, purpose, and completion status of each.

ADDICTIONS TREATMENT - Please list clinicians (physician, counselor...) or treatment centers that provide(ed) service to you. Identify type of treatment (detox, residential, outpatient...), dates of treatment, and treatment status (still involved, successfully completed, withdrew, etc). (copy)

CRIMINAL JUSTICE INVOLVEMENT - Please list your involvement with criminal justice. Identify type and dates of involvement (arrests, incarceration, probation, parole...).

Activity Interests (Please check all items that interest you)

This section is to help us understand areas of life where our potential residents would like community support, companionship, or learning opportunities through mentorships, classes, or the development of sober social clubs.

I am committed to my recovery and ongoing abstinence from alcohol and drugs (other than prescribed)

Yes
No

I will support my peers in recovery to the best of my ability

Yes
No

I have a minimum of 90 days in recovery from alcohol and other drugs (unless prescribed)

Yes
No

I will be a college-level or trade school student while I’m a resident at the house

Yes
No

I will work or volunteer as specified in my Individual Lifestyle Plan

Yes
No

I will abide by my contractual agreement with the house

Yes
No

I will treat the house property and my housemates with respect

Yes
No

I will take personal responsibility for notifying the house representatives of any issues or concerns while I’m a resident

Yes
No

I will contribute to a cooperative, peer support house culture

Yes
No

I will follow the house rules established between myself and my housemates

Yes
No

I will give back to my community through volunteer projects

Yes
No

I hereby certify that all the information I provided in this application is accurate to the best of my knowledge. I also understand that AJM Foundation, Aaron's House, and Grace House will not disclose any of this information to any other party without my written authorization via a specific release/disclosure form. I am aware that additional information may be necessary before final approval is made regarding this application. *

Applicant Signature & Date

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Bridging the gapbetween treatment and community living.